Quality Accounts 2020/2021 - Demelza Hospice Care for ...
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Quality Accounts 2020/2021
Part 1:
Statement of quality by the Acting CEO
In the midst of a global pandemic, it is with great pleasure that I present Demelza Hospice
Care for Children’s Quality Account. I am proud to say that our clinical services’ COVID-19
infection outbreak record is zero. We will continue to navigate our way with the same levels of
clinical safety at all times whilst offering high quality care for our children, young people and
Contents
families.
Page number This year has been a year like no other – children and families nurse to return to an adult ITU in the local general hospital and
Lavinia Jarrett have remained at the centre of our decision making along with provided additional resource to local adult palliative care
Acting Chief Executive Officer the safety of all colleagues and volunteers involved in the direct services. In return, we received the valued help and support of
and ancillary care. local children’s nurses from other NHS Trusts and from a recently
Part 1: Statement of quality by the Acting CEO 3
retired Demelza Registered Nurse who immediately returned to
During the pandemic, we have adapted our services to continue regular duty.
Part 2: Review of quality performance 2020/21 4-5 to offer a virtual lifeline to the vulnerable, who were severely
• 2.1 What we achieved in 2020/2021 5-7 impacted by spending months isolated and shielding. We Throughout the pandemic, Demelza implemented rigorous
• 2.2 Looking back - patient safety 2020/21 8-9 developed a weekly timetable of virtual sessions to appeal to a infection prevention and control policies, procedures and training,
wide range of children, young people and families and some and secured the essential equipment that enabled safe clinical
• 2.3 Looking back - clinical effectiveness 2020/21 10-11
were targeted at specific family members. One-to-one and group care to continue for all emergency admissions including end of
• 2.4 Looking back - patient experience 2020/21 12-15 virtual sessions were set up with therapy and family support liaison life care, social care placements and symptom management.
colleagues. Our volunteers also supported by delivering therapy Demelza rolled out rigorous testing regimes for all staff and
Part 3: Priorities for improvement 16-17 bags, Easter eggs, and Christmas presents; they also continued to volunteers who could not carry out work from home as early as
• 3:1 Key priorities for improvement 2021/22 16-17 support travel to hospital and other essential appointments. possible to ensure we could safely restart our offer of respite care
to children and families.
• 3.2 Future planning – patient safety 16-17
We were able to offer access to our wonderful facilities, so
• 3.3 Future planning – clinical effectiveness 16-17 generously funded by our donors, so that individual families could These accounts have been prepared by our Director of Clinical
• 3.4 Future planning – patient experience 18-19 enjoy a session in their ‘bubble’ in the hydro pool, the sensory Services and her team, with the full support of Demelza’s Board of
room, the playground, the garden or the cinema room. For many, Trustees.
Part 4: The Board of Trustees commitment to quality 20-21 it was the first venture into the outside world for many months.
Thank you
Part 5: Statements of assurance 22-25
I am extremely proud to report that Demelza was able to support
Part 6: What others say about us 26-27
Part 7: Service data 28-33
the national efforts of the NHS and other colleagues during the
pandemic by offering step-down care to several children, as well
Vin
as a young person not on our caseload, to relieve the pressures Lavinia Jarrett
on London hospital resources. Demelza supported a specialist Acting Chief Executive Officer
Quality Accounts 2020/2021 | 3
Part 2:
Review of 2.1 What we achieved in 2020/2021?
When setting out our strategy for 2020/2021, no-one could have • Step-down care for children on long term ventilation referred
quality predicted that we would be experiencing an ongoing global
pandemic. We took quick action to suspend non-essential face-
to-face services to protect vulnerable people from the spread of
infection and maintain capacity for end of life and other urgent
from Evelina London Children’s Hospital.
• Bereavement care and use of bereavement suites.
• Residential stays for children who were unable to be safely cared
for at home, and for those being treated in tertiary NHS hospitals
performance care and adapted our services to enable us to virtually support
hundreds of families.
to free up beds, and reduce infection risk for those children
• Urgent short breaks where capacity allowed.
• Supported training within the hospice for external provider staff to
2020/21
Despite the uncertain times we have made progress against our become competent in an individual child’s ventilation needs to
2016-2021 strategy that was superseded in October 2021 with support the child and family to return home.
our 18 month Reset and Recovery Plan that is tailored to the more • Regular welfare calls to families and video contact with families
unpredictable landscape resulting from the pandemic. and professionals.
• ‘Little Dots’ play sessions for younger children were moved from
Prioritising those in greatest need: hospice-based to online ‘virtual’ sessions enabling more families
Since the start of the pandemic, we have focused on capacity for to join.
urgent care, to support the NHS, and to help those children and • Provision of activity bags to families whose short breaks were
families with the greatest need. We have checked on the welfare cancelled (South East London).
of the families we support and identified alternative support that • Practical support for families such as delivering shopping and
could be offered. Additionally, we have adapted our services medication, and delivering ‘essentials’ boxes which were
to better utilise technology and digital platforms to enable us to donated by the Jack Jeffreys Superhero Trust (East Sussex).
support more families. • Supported children to attend essential hospital appointments.
• Provided 20 hours per week of commissioned care to one family
Throughout the pandemic the following clinical services throughout lockdown (East Sussex).
were provided: • Offered families access to the sensory room in East Sussex and
hydro pool and cinema spaces at Kent, when Government
Nursing and care: guidance allowed.
• End of life care in the Kent and South East London hospices.
• East Sussex worked together with Children’s Community Nursing
and Chestnut Tree House Children’s Hospice on a shared rota to
support end of life care at home.
Quality Accounts 2020/2021 | 5
2.1 What we achieved in 2020/2021?
Family liaison:
• Individual sibling support sessions.
• Weekly support groups for siblings aged 5 – 11 years old.
• Recorded series of videos on resilience, emotions and
pre-recorded activity sessions for parents and siblings.
• Support helpline for parents and carers 10am – 4pm every
weekday.
• Individual follow-up welfare calls and telephone support for
parents.
• Weekly question and answer sessions involving problem solving
and peer support for parents between 10am – 11am
on Fridays.
• Volunteers phoning grandparents for welfare calls.
Therapies:
• Art and music therapy sessions for children and families onsite in
Kent and SEL.
• Virtual art therapy sessions for families via zoom six times a week.
• Music therapy sessions for families in homes.
• Virtual individual family one-off music therapy sessions via Zoom.
• Saturday morning music therapy.
• Tuesday play specialism individual family sessions
“
I am writing to express my sincere gratitude with all my heart for looking after my beautiful granddaughter.
Thank you for being so caring, considerate, compassionate and comforting during the sad loss of our baby.
You were also very accommodating allowing me to be with my family at Demelza, especially during these
current times of the coronavirus pandemic lockdown restrictions. You listened to us during our times of tears,
anger, laughter, play and conversations. You were there for us in our time of need. “
Feedback from a grandmother
Quality Accounts 2020/2021 | 7
2.2 Looking back - Patient safety 2020/2021
Infection Prevention and Control (IPC) safeguarding across the breadth of the organisation,
Successes include: embedding the ‘safeguarding is everyone’s business’
• Identified and defined an IPC Lead Nurse role, this enabled us message. Chaired by the Clinical Safeguarding Trustee.
to continuously review and implement changes in line with the – Regular safeguarding supervision for staff, with both internal
national guidance in a timely manner. Including: and external facilitation.
– COVID-19 Infection Prevention and Control Clinical – S ourced external training for levels 3, 4 and 5.
Guidelines, providing clear policy and procedures for – M onthly face-to-face safeguarding sessions for levels 2
clinical teams. These were approved by an external IPC and 3.
specialist. – Increased profile of our six Designated Safeguarding
– Infection Prevention and Control Board Assurance and PREVENT Leads across the organisation including a
Framework, benchmarking Demelza against local NHS safeguarding section in our monthly staff newsletter.
Trust Policy.
• All hospice sites have remained open and able to safely Clinical safety improvements
deliver direct care to children. This included: end-of-life care Successes include:
in hospices and at home; step-down care; emergency short • Clinical Safety Lead Nurse identified with defined role and
breaks in hospices and at home. responsibilities. This has given us the opportunity to drive the
• Training and support delivered for all care staff on safe usage of following improvements:
personal protective equipment (PPE). – Reflective statement template updated.
• We have supported children whose parents have tested positive – Significant event audit training attended by all senior
for COVID-19 and were unable to care for them at home. nursing and family liaison and support colleagues.
• There have been zero clinical outbreaks of COVID-19. – Consideration for second victim potential and measures
put in place to mitigate this.
Safeguarding children and adults • Weekly clinical safety meetings chaired by the Deputy Director
Successes include: of Nursing and Care and attended by Lead Nurses from each
•Safeguarding Lead Nurse identified with defined role and site, and Director of Clinical Services as required, allowing
responsibilities. This has enabled us to review our safeguarding discussion and future planning of clinical requirements and
policy and practice with considerable improvements: have strengthened quality and safety.
– Safeguarding training matrix review and implementation,
including integration of safeguarding adults and review of
our e-learning for levels 1 and 2.
– Launch of new Safeguarding Assurance Committee,
meeting quarterly as a multi-professional group to review
Quality Accounts 2020/2021 | 9
2.3 Looking back - clinical effectiveness 2020/21
Clinical education programme
Successes include:
• Based on staff feedback prior to the pandemic, changes were
planned for our clinical training programme to be responsive to
our teams identified needs and mandatory expectations.
• A virtual training programme was instigated. This included all
clinical staff access to eLearning for health platform, as well as
Demelza bespoke courses.
Clinical services development
Successes include:
•Virtual meetings of the Parent Carer Forum took place and
their recommendations for improvement were actioned. For
example, we made improvements to how we communicate to
parents via email.
• The Parent Carer Forum voted for and nominated one of their
members to become a trustee, to offer a parent voice on the
trustee board.
• Surveys were sent to seek feedback from families regarding
their experience of our services and these were responded
to where appropriate, for example, by referring families to the
practical support team if they had requested this.
• Families were offered the option to register to be contacted
about short notice short breaks. Responses were registered
on our database, enabling nursing and care staff to contact
families to offer short breaks when the hospices had availability.
Quality Accounts 2020/2021 | 11
2.4 Looking back - Patient experience 2020/21
Mohammed Yahya’s story
At Demelza, we care for children of all ages, from older “Thanks to Demelza, we were confident enough to be able to
teenagers all the way down to the tiniest babies. For each child bring Mohammed Yahya home, for the first time, three weeks
our goal is the same; to give them the best quality of life we can later. We knew it would only be for a short few days or weeks – but
– to give them moments of happiness and fun that will become Demelza’s team gave us Demelza’s phone numbers so we knew
their parents most precious memories for the rest of their lives. they were only a call away.”
Mohammed Yahya’s care was challenging, his needs were In the end, he just died very quickly. He did not appear to be in
complex and required a lot of clinical expertise to interpret. His any discomfort, he just stopped breathing. I was holding him, as
apnoea’s (when he would stop breathing, happened a few times I’d promised his parents. They came down and I gave their baby
a day) and his reflux meant we had to be constantly vigilant of back to them – and comforted them as best I could as they held
his situation. Reflux is a burning feeling caused by stomach acid him. Our journey with Mohammed Yahya’s parents won’t stop
travelling up towards the throat. He had a feeding tube, which there – we always keep in touch with our families and offer them
we would test to check it was in the right place before feeds. We bereavement support.
found it was often easiest to keep an eye on him if we just held
him all the time. Sarah Jesson, Registered Nurse
We got the family to a point where they were able to manage
his care and felt confident enough to take him home for the
“
first time, this was a massive milestone for them as a family. We
continued to support them and when needed they would come
back to stay at the hospice, they did this on four occasions.
In our time there what quickly became clear was that the
Abdul, Mohammed Yahya’s Dad said: “In our time there what Demelza team weren’t just lovely, caring people; they also
quickly became clear was that the Demelza team weren’t just clearly had the most exceptional medical knowledge and
lovely, caring people; they also clearly had the most exceptional
medical knowledge and experience of caring for babies like experience of caring for babies like Mohammed Yahya.
Mohammed Yahya. They knew exactly how to care for him, and They knew exactly how to care for him, and they trained us
they trained us too.
too. “
Abdul, Mohammed Yahya’s Dad
Quality Accounts 2020/2021 | 13
2.4 Looking back - Patient experience 2020/21
Virtual family support and therapies Family engagement
Our family support teams’ family-centric approach saw them The family events lead role was identified and recruited, enabling
introduce reading sessions during school closures, organise us to offer families virtual events, including a programme of winter
activities to combat isolation, such as virtual parties and create and festive themed events in December 2020. We also ran an
online age specific sibling groups, alongside an engaging weekly inclusive dance workshop and sensory story craft parties.
support programme.
We organised two milestone events for bereaved families, called
Family support also created a designated weekday helpline the Candlelight and Snowdrop events. Our Snowdrop event saw
and called over 100 families for Time to Talk Day. This resulted in us deliver bespoke event boxes to families which included an art
an improved overview of caseloads and contact with families. therapy craft activity.
We also did regular updates on our Demelza families group on
“
Facebook and weekly emails were sent to families.
We created a new booking system for families looking to access
our hydro pool, cinema space, sensory room and gardens, when Beautiful. Such thought and care. Knowing that Demelza
government guidance allowed. were thinking of me and my boy. Really liked that it was
Changes to our bereavement support services delivered by someone from Demelza. So very kind.
Our new bereavement service model was agreed and the new Great idea to have everything you needed to make
bereavement volunteer team were recruited and training was
delivered in partnership with Holding on Letting Go, enabling the
the snowdrop, even the glue! The tile is very special
team to be ready for the opening of new services as part of our and already framed. The heart keepsake is simple and
new bereavement model. beautiful. I will always know that it is for my boy, without
We have launched new Facebook groups to support families; necessarily having his name on it and others asking who it
including: a bereavement group, a dad’s group and a
grandparents’ group. We have further groups planned for
is for.
“
2021/2022. Feedback from the Snowdrop event
Quality Accounts 2020/2021 | 15
Part 3: 3.1 Key priorities for Priority 2: Safeguarding
This will be achieved by the following:
– We want to equip and empower families to access
all necessary information and be in contact with
between service providers in health and social care. We
will look for opportunities to collaborate with health and
improvement 2021/2022
Priorities for
• We will continue to raise the profile of safeguarding within the relevant agencies that can support them through the social care organisations across all of the areas where we
organisation and continue to improve our working practices many aspects of transition. This will therefore form the provide services to ensure that Demelza is linked to external
The below key priorities will enable us to continue to be focused and embed safeguarding across the whole organisation. foundation of decisions regarding support to be offered organisations to achieve the best outcome for the child.
on providing a high quality, safe, effective and sustainable • Demelza will be working to establish and incorporate ‘the by Demelza once young people reach 18 years. • Family Support will continue to develop a hybrid approach
improvement
palliative and end of life care for the children and families who voice of the child’ into future work and will be seeking external • Equality, Diversity and Inclusion (EDI): of online and in-person support. Online sessions are delivered
need us. advice on this. – We are striving to continually improve our approach to via Zoom and continually extend reach to families via
• We will continue to develop the Safeguarding Assurance EDI, in collaboration with another children’s hospice. The the Demelza Families and Demelza Bereaved Families
As COVID-19 uncertainty continues, we will continue to Committee meeting to improve outcomes and increase EDI work stream started with a workshop in March 2021. Facebook closed groups. Further to the weekly email
be flexible and responsive of the situation, which will be safety across the organisation. We want to ensure that: updates with details of all online events or sessions and online
underpinned by our Reset and Recovery Plan. This plan was > all people feel welcome and comfortable when systems for surveys and event bookings, a series of ‘Dem
developed in partnership with families, staff, volunteers and receiving care or support from Demelza; Talks’, similar to Ted Talks, for bereaved families is planned.
supporters.
3.3 Future planning – > that we have a diverse staff and volunteer
workforce that benefits from the innovation and
clinical effectiveness
3.2 Future planning – richness that diversity brings;
> that we play our part in making a fairer society by
patient safety Priority 1: Reach and equity of service provision tackling prejudice and privilege.
This will be achieved by: – We will develop knowledge, skills and awareness of
Priority 1: Focus on medicines management • Review of our caseload: diversity, including considering how care and support
This will be achieved by: – Utilising data available to us identify gaps between can be improved for people from all cultures, those with
• The focus for 2021/2022 will be medicines management, estimated prevalence of children and young people faiths, beliefs and religions and those without. Demelza
recognising the inherent risks of nurses transcribing and with life-limiting conditions across the areas we serve, proactively seeks to identify and remove prejudice and
maximising the provision we have with a highly specialised and our current caseloads. discriminatory practices relating to race, ethnicity, culture,
pharmacist, as well as a pharmacist clinical trustee. In – Outcomes from the above will drive focussed work to sexuality, gender, disability, age, marriage or partnership
2021/2022 we will: reach the additional children and families eligible to status, and social class.
– Commence quarterly Medicines Management access our services. – Demelza are seeking to build a network of stakeholders
Assurance Committee meetings. The committee will: – In addition, we will review our discharge process to who can further engage with people we are less
share current best practice and medicines management ensure that caseloads accurately represent children and successful in reaching. Plans will be published within the
updates; explore all clinical medicine management families eligible and wishing to access our services. 2022 strategy.
incidents and near misses, identify themes; make • Short break booking system review:
suggestions for improved practice; and monitor progress. – Exploring a new long-term solution for booking short Priority 2: Digital transformation
– Review and update all policies and procedures in relation breaks that will protect our ability to be responsive to An overarching digital transformation strategy is being
to medicines management. the core service provisions of end of life care, symptom developed which sets the tone, scope and direction for
– Launch electronic drug charts at residential hospice sites. control and bereavement support, whilst maintaining the this work. For the success of this project, this cannot be a
– Explore the potential to support two senior registered vital short break provision that our families rely on. standalone piece of work and must form an integral element
nurses to obtain non-medical prescribing status. • Transition working party: of all other strategies and projects across Demelza. This will be
– The transition steering group is currently defining our achieved by:
transition offer, which will be finalised in line with the 2022 • Becoming a partner organisation with the Kent and Medway
strategy. Care Record, which supports sharing of information
Quality Accounts 2020/2021 | 17
3.4 Future planning –
patient experience
Priority 1: Expanding and embedding the voice of the child Priority 2: Flexibility and responsiveness for place of care and
and family support
This will be achieved by: This will be achieved by:
• Enhanced service user involvement: • We will continue to balance on-site, face-to-face sessions and
– Our new Service User Engagement Lead will be responsible therapeutic experiences for Demelza families with a continued
for ensuring the design and delivery of Demelza’s services is and expanded virtual presence.
informed by an evidence-based understanding of service • We will monitor the services offered and update and develop
user needs, wishes and feedback, maximising our impact them to ensure that they remain current and supportive of our
on children, young people and their families. family’s needs and wishes.
– We will develop and embed a culture of engagement • This flexible approach, underpinned by a clear service model
with children, young people, parents, carers and other is informed by national service standards and shared good
family members in designing, informing and influencing the practice within the children’s hospice sector, alongside direct
services we provide. feedback and review by families.
– We will develop and implement a service user engagement • Expansion of Care at Home service:
strategy, focused on providing opportunities for service user –W e will seek to expand these services to include end of
to participate at different levels to ensure their feedback is life nursing support in the community to allow children and
actioned. families greater choice and control over place of death.
– We will offer a variety of ways for service users to engage • Managed clinical networks:
with us and have their views heard and enable them to –W e will work collaboratively with the Kent and Medway
influence and co-produce services. Managed Clinical Network (MCN) to maximise available
– Family Events continue to be shaped and developed using workforce and resources to allow children and families
feedback from families and the voice of the child. greater choice about place of care.
• Review of key policies and processes to ensure the child’s voice –W e will learn from the successful working relationships with
is adequately represented: local children’s community nursing teams and Chestnut Tree
– Safeguarding policy review House Children’s Hospice and develop a similar approach
– Professional boundaries policy review for South East London.
– Consent policy review –W e will ensure we are represented and contributing to The
• Dignity and respect policy review London Children’s Palliative Care Network.
• Datix incident reporting policy
• Website development project:
– As part of a wider review of our website, consideration will be
given to increasing accessibility of information for all ages,
developmental stages and communication preferences.
Quality Accounts 2020/2021 | 19Part 4: Part 4:
The board The board of trustees commitment to quality
of trustees
We are committed to our staff, volunteers, families and children to help those who may not
live a long life to live life to the full.
commitment
We take our governance responsibilities very seriously and ensure Each Clinical Governance Committee meeting reviews the clinical
that all trustees are briefed at every board meeting by the Chair governance and quality progress and incident reports which are
of the Clinical Governance Committee on progress in clinical discussed in detail.
developments as well as highlighting challenges and concerns.
to quality
A patient story is told at each meeting to ensure that trustees Key performance indicators, family and service user feedback
appreciate what children, families and staff are dealing with. and the clinical risk register is considered in detail at each
meeting.
The Clinical Governance Committee has representatives from the
clinical services leadership team, four clinical trustees, including The clinical services team have been strongly involved in
a community paediatrician, a pharmacist, senior nurse and lead developing and delivering our reset and recovery plan.
clinician from the Health Ombudsman’s office. We’ve recently
appointed a parent trustee who has brought a rich level of We are confident that the treatment and care provided
observation and scrutiny from a parent’s perspective. by Demelza is of the highest quality detailing a continuous
improvement whilst ensuring it is cost effective and efficient.
Demelza’s established clinical governance structure ensures that
trustees are confident in their role as a ‘critical friend’ but also There is no formula, everyone’s journey is unique.
comfortable in undertaking robust challenging conversations with
the nursing, care and family support team. We have prioritised
safeguarding to ensure that ‘safeguarding is everyone business’
across the organisation and all trustees have completed
safeguarding training. We have robust safeguarding processes in
place.
Quality Accounts 2020/2021 | 21Part 5: Part 5:
Statements Statements of assurance
of assurance
These statements are ones set out within Quality Accounts Infection prevention and control (IPC)
Regulations that all providers must include. Infection prevention and control has been fundamental to safe
service provision throughout 2020/21. More details on this can be
Review of services found in Part 2 of the quality account.
Demelza worked closely with partners, including NHS Tertiary
Centres, other hospitals, local adult hospices, community nursing In April 2021, Demelza hosted the NHS Deep Cleaning and
teams, NHS England, CCGs and local authorities to collaborate Advisory Service in order to benchmark housekeeping and
and focus support where it would be most beneficial. cleaning within the Kent hospice and received positive feedback
available on page 27.
Collaborating with other providers
As mentioned, in this report we have collaborated with other Our reset and recovery plan clearly outlines how Demelza can
providers and supported the NHS during the pandemic. safely emerge from the current COVID-19 restrictions, whilst
maintaining the safety of staff, volunteers and families.
Participation in national audits
In 2020/2021 there were no audits or enquiries relating specifically The IPC Lead Nurse is responsible for continual review and
to specialist children’s palliative care. updating of the infection prevention and control Policies and
Procedures and for alerting the Senior Leadership Team of any
Local clinical audits areas requiring attention.
We have a programme of internal clinical audits ensuring quality
and performance are measured and monitored, meeting our
statutory and regulatory requirements, as well as for informing risk
management.
Audit tools are based upon Healthcare Quality Improvement
Partnership best practice guidance. Whilst the clinical governance
team plan and instigate clinical audits, a whole team approach
to completing them is adopted. This ensures understanding and
ownership of findings and recommendations.
Audit findings are presented quarterly to the clinical governance
committee meeting, as well as being shared across our internal
communication channels.
Quality Accounts 2020/2021 | 23Part 5:
Statements of assurance
MHRA and patient safety alerts Demelza supported the following external research requests in
There is a formal system in place for the receipt, review and 2020/21:
actioning of all MHRA alerts. A designated nurse reviews all alerts. • University of York SWiCH survey.
On identification of ones relevant to Demelza, these are shared • Masters student survey regarding the role of the pharmacist /
via email with a very clear ‘problem’, ‘risk rating’ and ‘action pharmacy technician in paediatric palliative care.
required’ format. Any high-risk areas are also printed and shared • Children’s Palliative Outcome Scale (C-POS) study from Kings
on information boards and within clinical handover. College London.
• Children’s Cancer Priority Setting Partnership survey.
This year has seen a recall for remediation of McKinley T34 syringe • Birmingham University survey evaluating perinatal advance care
drivers and this has been carefully and successfully managed. plans.
Additionally, there have been numerous new national guidelines • North Dakota State University exploring the lived experiences of
published in response to the COVID-19 Pandemic. The IPC lead bereavement support professionals at children’s hospices in the
nurse, alongside the clinical governance team, have managed UK.
these and ensured timely implementation. • PhD student interview study examining parental and
organisational perspectives into how parents of children with
Research medical conditions seek and access support for themselves.
We value and encourage research into children’s palliative care.
As such, all external research requests are considered on their
merit and, if required, the Clinical Governance Committee will
review papers and receive a presentation from the researcher to
ascertain appropriateness of participation. A formalised process is
planned for 2021.
Quality Accounts 2020/2021 | 25Part 6: Part 6:
What others What others say about us
say about us
Care Quality Commission (CQC): “(Demelza Kent is) very well maintained to an exceptional high
Demelza Kent, South East London and East Sussex are individually standard throughout. They have gone above and beyond in
registered by the CQC under the Health and Social Care Act their protocols, procedures and risk assessments – the detail in
(2008). Demelza East Sussex was registered as a separate service the planning is absolutely incredible”.
in July 2020.
Data quality
Demelza South East London was last inspected in 2017 and was In 2020/21 Demelza collected and submitted data in respect of
rated “good” overall and “outstanding” in being responsive to the the following:
needs of the child, young person and their family. They found that • CQC for child death data and reports of significant events/
staff often went beyond the scope of their duties to show that they investigations.
cared. • Quarterly clinical governance and quality reports to the Clinical
Governance Committee.
Demelza Kent and East Sussex were registered as a combined • All relevant information to the quarterly board of trustee’s
service and were last inspected in 2016 and was rated as meeting.
“outstanding”. “There was an open and positive culture which • Service mapping information submitted to Together for Short
focussed on children and how to enhance the quality of their life,” Lives.
says the report. • Finance data submitted to Hospice UK.
• Capacity tracker data continues to be recorded and submitted
Demelza’s current registration status is unconditional, with no to NHS England daily, including weekends and bank holidays.
enforcement actions or participation of special reviews or • Data provided to the Child Death Overview Panel.
investigations throughout 2020/21. • Data submitted to London Borough of Bexley and Greenwich
Clinical Commissioning Group.
Demelza participated with the CQC’s transitional monitoring • Clinical coding error rate.
approach (TMA) in March 2021. The feedback from this was: • Demelza are not eligible to submit to the summary hospital level
“At this moment we are unable to provide any quality statements. mortality indicator and are not subject to the payment by results
We are however happy to recognise the collaboration with clinical coding audit.
Demelza in regards to engagement and the TMA and COVID-19
assurance framework, which for the time being indicates no Areas for further improvement
serious risks identified.”. Despite no external quality visits during 2020/2021, we are
committed to striving for continuous improvement and
NHS deep cleaning and advisory service: are currently reviewing our clinical governance and quality
Following an invitation from Demelza to visit and review Demelza improvement plan to be implemented from October 2021.
housekeeping and cleaning standards in light of increased
requirements due to the COVID-19 Pandemic, the NHS deep
cleaning and advisory service stated that:
Quality Accounts 2020/2021 | 27Part 7: Part 7:
Care at Home hours 2020-2021 Event and Group Attendance Figures (Jan to March 2021)
Service Data Service data 4000
3549
600
Number of hours
3000 500
400
2000
Activity Report 971 300
1000
Demelza undertook a review of clinical key performance
105 200
indicators in 2020/21. An important aspect of this is the 0
number of unique children and families reached. This East Sussex Kent South East London 100
has allowed us to examine the equity of the service and
ensures that we strive to reach the maximum possible 0
number of different families. Data is provided to the Clinical Child Sibling FM
Governance Committee quarterly outlining the following:
Hospice usage 2020-2021
• Hospice overnight bed occupancy.
1000 Number of Family Led Bookings 2021-2021
• Hospice day care. 876 880
• Care at home and community care sessions provided . 800 200
• External Hydro pool bookings.
• External Cinema room bookings. 600 150
• External sensory room bookings.
• Types of care delivered: emergency respite; symptom 400
100
management; step down care from hospital; end of life
200
care, offers of short breaks. 50
25 23
• Numbers of deaths and place of death. 0
• Bereavement suite usage. Nights Day Care 0
• Family liaison contacts. Sensory Room Hydropool Cinema Space
Kent South East London (East Sussex) (Kent) (Kent)
• Bereavement support and therapies sessions provided.
• Family events and virtual group session attendance.
• Training compliance figures.
• Activity levels from the reset and recovery milestones.
Family Support Department
Event & Group Attendance Figures (Jan to Mar 21)
Child 408
Sibling 201
FM 546
Total 1155
Quality Accounts 2020/2021 | 29Clinical Datix 1 April 2021 - 31 March 2021 Clinical Services Training compliance April 2020 - March 2021
35
Part 7: 30
100%
90%
Service data 25 80%
70%
20
60%
15
50%
Incidents, accidents, complaints and compliments
10 40%
We utilise the Datix incident reporting system across the
5 30%
organisation. The data below demonstrates a positive
culture of incident reporting within clinical services, further 20%
0
attention is planned to improve ‘near-miss’ reporting to build 10%
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upon the figure of 22 reported near misses for 2020/21. 0%
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Fire Safeguarding Moving & Data Infection MCA & DOLS
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Throughout 2020/21 there has been encouragement for
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June September March
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staff to also report compliments; this has been well received
te
En
and is a constructive tool to encourage teams to recognise
and applaud behaviours that align with Demelza values.
Demelza clinical services received 1 complaint, 1 comment
and 41 compliments within 2020/21.
Medication error by sub-category 1 April 2021 - 31 March 2021
Wrong/unclear dose Non Care Support Services & Fundraising – Training compliance
or strength Omitted medicine/ingredient April 2020 - March 2021
Wrong/transposed/ Omitted medicine/ingredient
omitted medicine label 100%
90%
80%
Wrong storage 70%
60%
50%
Wrong quantity 40%
30%
Other
20%
10%
Wrong method of 0%
Unknown Fire Safeguarding Moving & Data Infection
preparation/supply handling Protection Control
Wrong frequency June September December March
Quality Accounts 2020/2021 | 31Part 7:
Service data
Finance and sustainability: Equality, diversity and inclusion:
Demelza is in a strong financial position. We have made a surplus We understand that celebrating and embracing the unique
in four of the last five years. Our expenditure is well controlled, and differences people bring will engender a creative, forward thinking
has been increasing by an average of 10% per year over the last organisation.
10 years. Our main income streams usually have the following
proportions: Demelza is striving to continually improve its approach to equality,
diversity and inclusion.
Fundraising 28%
Retail 26% Demelza have identified a need to improve racial equality and
Statutory Funding 15% have committed to addressing this problem. Whilst we are proud
Lottery 15% that the profiles of our service-users match the ethnic profiles
Legacies 12% of the communities in which we work, this is not the case for our
Dividends & Interest 2% workforce or leadership roles. We are formulating a plan, with
Others 2% support, to address this serious issue, for the benefit of the people
and communities we serve and to improve our organisation. We
We have received two large legacies in 2018 and 2020 totalling welcome the advice and guidance of anyone who can help us
£7.5m. Due to the legacies and careful financial management, achieve this aim.
Demelza has strong reserves. At 1 April 2020 we held £17m in free
reserves, which is £4.3m more than our reserves policy. This allows Safeguarding:
us to weather the financial uncertainty brought by the COVID-19 A significant amount of progress has been made over the
pandemic, and to continue to plan for growth and sustainability. past year, including the review of our safeguarding policy and
We expect to use these excess reserves over the next strategic procedures, training matrix, training programme and providers,
period as we develop our care teams and invest in our main introduction of our’ Safeguarding Assurance Committee’ and the
forms of income generation: fundraising, retail and lottery. We are implementation of regular safeguarding supervision for staff. We
committed to using our strong reserves to reach more children have strengthened our links with our local authorities and acute
and families. safeguarding leads in all 3 areas and established improved links
with our local Child Death Review teams and processes.
Duty of candour:
Demelza have followed all duty of candour processes for all
incidents involving children and young people.
Quality Accounts 2020/2021 | 33Demelza Kent
Demelza House, Rook Lane,
Bobbing, Sittingbourne,
Kent, ME9 8DZ
01795 845 200
info@demelza.org.uk
Demelza South East London
5 Wensley Close,
Eltham,
London, SE9 5AB
020 8859 9800
info@demelza.org.uk
Demelza East Sussex
150a Bexhill Road,
St Leonards On Sea,
East Sussex, TN38 8BL
01323 446 461
www.demelza.org.uk
info@demelza.org.uk
*Some photos featured in this document were taken pre COVID-19 Registered Charity Number: 1039651You can also read
